Commencement For Collaborative Practice
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2ALABAMA STATE BOARD OF MEDICAL EXAMINERS
848 Washington Ave. (36104)
PO Box 946, Montgomery AL 36101-0946
(334) 242-4116
Instructions for Commencement of Collaborative Practice
The Collaborating Physician is required to submit the following form and fee for the Registration
and Commencement of Collaborative Practice to the Alabama Board of Medical Examiners
1.
The following information must be complete or form will be returned:
a.
Physician's name, license number and practice address
b.
CRNP/CNM name, license number and practice address
c.
Completed Quality Assurance Plan
2.
Original Signature of the Collaborating Physician attesting to the required information.
3.
Remittance of Collaborative Practice Fee of $100.00 payable to: Alabama Board of
Medical Examiners.
Notice: Until this Commencement Form and Fee are received this Collaborative
Agreement will NOT be issued Temporary Approval by the Alabama Board of Nursing.
Collaborative Practice Rule 540-X-8-.04 (1)(a-c)4/540-X-8-.18 (1)(a-c): Qualifications for
Physicians in Collaborative Practice with Certified Registered Nurse Practitioner/Certified Nurse
Midwife:
(1)
The physician in collaborative practice with a certified registered nurse
practitioner/certified nurse midwife shall have:
a.
A current, unrestricted license to practice medicine in the State of Alabama; and
b.
Practiced medicine for at least one year, if the physician is certified by or eligible for
board certification by a specialty board approved by the American Medical Association or by
the American Osteopathic Association; or have practiced medicine,(for CNM's including the
active practice of obstetrics and /or gynecology), for at least three years.
c.
Paid all collaborative practice fees due to the Board of Medical Examiners and submitted
to the Board of Medical Examiners, the appropriate registration forms.
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